advantages from using EOS system at Medic Center Vietnam in comparison to older method of film stitching in cases of scoliosis, inferior extremity disorders, 3D view of vertebral column, hip joint, knee joint.
6. EOS : a new dimension to
radiological outcome
NGUYEN VAN CONG MD, RADIOLOGIST
MEDIC CENTER, HCMC, VIET NAM
7. ABOUT HOA HAO MEDIC CENTER,
HCMC, VIET NAM
www.medic.com.vn
8.
9. Activity of Medic Center
• Private clinic since 1990, with more than 700 employees in which there
are about 250 doctors.
• Director : Dr Phan Thanh Hai
• We work from 4 am to 7 pm (7 day a week)
• Around 1000 – 1500 patients/day
• Specialized in diagnostic purposes as Medical imaging:
– 3 CT scan machines (Toshiba Aquilion 1 with 320 detectors)
– 3 MRI of 1.5 tesla (Siemens, GE…)
– 10 rooms of conventional x ray using DR (Canon, Konica Minolta,
Samsung, Drtech…)
– 50 US machine (Siemens, GE, Samsung, Philips, Aloka…)
– Modern automated lab machines from Siemens, Roche, Abbott,
Horiba…
– 1 EOS system since October 2014
11. Clinical Goals & Challenges for MSK Imaging
Dose
Reduction
Diagnostic
Confidence
Throughput
Less Dose = reduced cancer risk
Reduced exam time :
-> more patients
-> better economical model
No stitching
High image quality
No Magnification
3D measurements
= reduced errors risk
12. CT scan of the spine
CT SCAN FOR FULL SPINE: SUPINE
POSITION , HEAVY RADIATION
Dose
Reduction
13. CT SCAN FOR FULL SPINE: SUPINE
POSITION , HEAVY RADIATION
Dose
Reduction
15. • Conventional stiching:
• Full spine= 2.5 mSv
• CT scan of the spine =10 mSv
Compared with EOS:
Full spine AP & LAT= 0,358 mSv – 0,470 mSv
( 1 Sv = 1 Gy = 1 J/kg)
Radiation dose in conventional stitching = 5-7 fold of EOS
system.
Radiation dose in CT scan = 21-28 fold of EOS system.
COMPARISON WITH OTHER MODALITIES
Dose
Reduction
16. Average skin dose reduced
from 6 to 9 times in the
thoraco-abdominal region
when using the slot-scanner
instead of CR with
equivalent or better image
quality(1)
Medical Imaging Radiation is a
Public Health Concern
(1)Diagnostic imaging of spinal deformities: reducing patients radiation dose with a new slot-scanning X-ray imager. Deschenes S, Charron G, Beaudoin G, Labelle H, Dubois J, Miron MC, Parent S. Spine (Phila Pa 1976)2010 Apr
20;35(9):989-94
(2)Comparison of radiation dose, workflow, patient comfort and financial break-even of standard digital radiography and a novel biplanar low-dose X-ray system for upright full-length lower limb and whole spine radiography.
Dietrich TJ, Pfirrmann CW, Schwab A, Pankalla K, Buck FM. Skeletal Radiol. 2013.
EOS provides upright full-length lower limb and whole spine
at 2 times less dose than the best tuned DR (2)
CR EOS
COMPARISON WITH OTHER MODALITIES
Dose
Reduction
17. Medical Imaging Radiation is a Public Health Concern
Micro Dose average
dose/examination is
equivalent to 7 days of
background radiation
COMPARISON WITH OTHER MODALITIES
Dose
Reduction
18. Micro Dose in MEDIC:
•For pediatric patients with leg lenghth discrepancy under 10
y.o
•In the future for pediatric patients which are coming for
scoliosis follow up
•For school screening program for scoliosis in HCMC?
The quality is good enough for measuring leg lenght or detect
abnormal curve of the spine
Dose
Reduction
20. Clinical Goals & Challenges for MSK Imaging
Dose
Reduction
Diagnostic
Confidence
Throughput
Less Dose = reduced cancer risk
Reduced exam time :
-> more patients
-> better economical model
No stitching
High image quality
No Magnification
3D measurements
= reduced errors risk
21. THROUGHPUT
Patient in the examination
room
Image processing
Transfer to PACS
Throughput
EOS DR (MEDIC)
Lower limbs
3 min 15 min
Spine
3min 15 min
22. Clinical Goals & Challenges for MSK Imaging
Dose
Reduction
Diagnostic
Confidence
Throughput
Less Dose = reduced cancer risk
Reduced exam time :
-> more patients
-> better economical model
No stitching
High image quality
No Magnification
3D measurements
= reduced errors risk
23. Diagnostic
Confidence STITCHING OF IMAGES
To obtain full spine or
full leg xray, at least 4
exposures are
needed, for AP and
lateral views
The patient much be
stand still for at least
60”
28. The limitation of x-ray imaging is
diagnostic error due to stitching
High rates of stitching
errors (16%) have been
reported and contribute to the
dissatisfaction of surgeons
with respect to the spine
radiographs produced
by stitching(*)
STITCHING OF IMAGES
Diagnostic
Confidence
(*) Diagnostic errors from digital stitching of scoliosis images – the importance of evaluating the source images prior to making a final
diagnosis .Nucharin Supakul & Keith Newbrough & Mervyn D. Cohen & S. Gregory Jennings, Pediatr Radiol (2012)
31. KEY POINTS
•We cannot do the whole body stitching.
•Difficulty with weak patient, motion artifact..can
reduce quality or failure to stich.
Diagnostic
Confidence
32. EOS allows full body AP/LAT acquisition
in one scan with no diagnostic error due
to stitching
Diagnostic
Confidence EOS: LINEAR SCAN -> NO STITCHING OF IMAGES
33. Full leg
length DR
stiching, 2
contrast
between
zones is
bad
Diagnostic
Confidence IMAGE QUALITY
EOS
homogeneous
image, high
image quality due
to automatic
ajustement of the
detector
34. Poor contrast
between zone
due to the
same
exposure
parameters for
different
zones
homogeneous
image, high
image quality due
to automatic
ajustement of the
detector
Diagnostic
Confidence
EOS
IMAGE QUALITY
37. We use e-film sofware to measure:
1st we must define the ruler by measuring the
width of a DR panel (35x43mm) and by that
ruler we make the mensurations which doesn’t
mean that we correct the beam magnification
Inaccuracy of mensuration
Diagnostic
Confidence
38. While EOS correct the magnification automatically with the software
and from the linear scan technology
EOS provide a true size image
70cm
80cm
70cm
70cm
Conventional xray EOS
Linear detector
scan
MAGNIFICATION OF IMAGES
Diagnostic
Confidence
39. KEY POINTS
Manually done and also due to xray beam
magnification, the measurement of length, angles
of the spine, lower limb are not accurate.
40. With 2 orthogonal xrays,
STEREOS can recontructs a
3D picture help us to measure
3D deformity in scoliosis,
malformation of lower limbs
etc…
3D MEASUREMENTS
Diagnostic
Confidence
45. Diagnostic
Confidence 3D MEASUREMENTS
2D can not evaluate
torsions and rotation
phenomena
EOS 3D measurements
allows for a more accurate
evaluation of hip-knee-ankle
(HKA) angle(6)
And femoral offset(7) compared
to 2D
(6)Evaluation of a new low-dose biplanar system to assess lower-limb alignment in 3D: a phantom study: P. Thelen & C.
Delin & D.Folinais & C. Radier, skeletal radiology, 2012
(7)Offset and anteversion reconstruction after cemented and uncemented total hip arthroplasty: an evaluation with
the low dose EOS system comparing 2 and 3 dimensional imaging: J.Y. Lazennec, A. Brusson, D. Folinais, M.A.
Rousseau, A.E. Pour, International orthopedics, 2014
The limitation of x-ray imaging is
diagnostic error due to inaccurate 2D measurement
46. Diagnostic
Confidence MEDIC patient Y: 2D measurements 1 view
Pelvic tilt: 2.1 cm
Right Leg: Valgus
Left Leg: Varus
Functional length discrepancy:
2.5 cm (left leg shorter)
Anatomical length discrepancy:
2.3 cm (left leg shorter)
2D diagnostic
47. Diagnostic
Confidence MEDIC patient Y:EOS + 3D measurements
3D diagnostic
Pelvic tilt: 2.1 cm
Right Leg: Valgus 5°
Left Leg: Valgus 12°
Functional length
discrepancy: 2.4 cm (left leg
shorter)
Anatomical length
discrepancy: 0,7 cm
(right leg shorter)
Knee flexion on left side 43°
48. Diagnostic
Confidence 2D measurement VS 3D measurements
3D diagnostic
Pelvic tilt: 2.1 cm
Right leg: Valgus 5°
Left leg: Valgus 12°
Functional length discrepancy:
2.4 cm (left leg shorter)
Anatomical length discrepancy:
0,7 cm (right leg shorter)
Knee flexion on left side 43°
2D diagnostic
Pelvic tilt: 2.1 cm
Right leg: Valgus
Left Leg : Varus
Functional length
discrepancy: 2.5 cm (left leg
shorter)
Anatomical length
discrepancy: 2.3 cm (left leg
shorter)
Only 3D weight bearing measurement
allows an exact assessment of patient
anatomy
60. Conclusion
EOS xray system with it advantages:
– Low radiation dose
– Fast workflow without stitching
– Hight image quality with good accurate measurements 2D & 3D
– Weight bearing positionning
EOS answers to the increasing demand of orthopedic
surgeons for accurate measurements.
So, EOS will replace old conventional stitching Xrays
61. Orthopedic activities in HCMC
Viet Nam
• In HCMC there are 4 hospitals specialized on
Orthopedic surgery, 3 rehabilitation centers for
treatment of spine deformation, leg length
discrepancy, hip and knee arthroplasty… (more
than 2000 cases per year)
• The need for orthopedic imaging with physiologic
weight bearing, acurate measurement of angles,
length…is increasing
PROMOTIONAL ACTIVITIES
How do we increase the number of patients?
63. 21st Annual Meeting of The Spine Society of Ho Chi Minh City in Nha
Trang in December 2014
PROMOTIONAL ACTIVITIES
64. Our guests from Thailand
PROMOTIONAL ACTIVITIES
21st Annual Meeting of The Spine Society of Ho Chi Minh City in Nha
Trang in December 2014
65. PROMOTIONAL ACTIVITIES
21st Annual Meeting of The Spine Society of Ho Chi Minh City in Nha
Trang in December 2014
Dr Nguyen Van Cong
(Radiologist EOS user at MEDIC)
Dr Vo Van Thanh
(Spine surgeon EOS user at MEDIC)
66. Prof Jorg Franke – Germany
Sagittal balance and the EOS System experiences from a German spine center
21st Annual Meeting of The Spine Society of Ho Chi Minh City in Nha
Trang in December 2014
PROMOTIONAL ACTIVITIES
Invitation of an international German speaker (EOS user)
67. Medic Center is private, we can afford best equipments to serve
our customers.
Quality, acceptable cost, time saving are our advantages
For EOS xray system mainly orthopedic patients sent by
surgeons, rehabilitation physicians, chiropractors...
PROMOTIONAL ACTIVITIES
From where are the patients coming to have an EOS in MEDIC?
68. ACTIVITY ASSESSMENT AFTER 6 MONTHS
• Number of patients in 6 month: 835
• Mean patient/day: 4 -> 8
• Max patient/ day: 10 -> 20
– Full body: 49%
– Full spine: 36%
– Full leg length: 15%
69. Thank You for your attention
Reference:
1. Diagnostic errors from digital stitching of scoliosis images – the importance of evaluating the source
images prior to making a final diagnosis
Nucharin Supakul & Keith Newbrough & Mervyn D. Cohen & S. Gregory Jennings, Pediatr Radiol (2012)
2, Ionizing radiation doses during lower limb torsion and anteversion measurements by EOS
stereoradiography and computed tomography: Delin C, Silvera S, Bassinet C , Thelen P, Rehel JL,
legmann P, Folinais D. Eur J Radiol. 2013.
(4) Ultra low dose imaging for the follow up of idiopathic scoliosis: How low is reasonably achievable with
new slot-scan technology? Alison M, Ferrero E, Tanase A, Rega A, Ilharreborde B, Mazda K, Sebag
G. Communication at RSNA 2013
5. Diagnostic imaging of spinal deformities: reducing patients radiation dose with a new slot-scanning X-ray
imager. Deschenes S, Charron G, Beaudoin G, Labelle H, Dubois J, Miron MC, Parent S. Spine (Phila
Pa 1976)2010 Apr 20;35(9):989-94
6. Comparison of radiation dose, workflow, patient comfort and financial break-even of standard digital
radiography and a novel biplanar low-dose X-ray system for upright full-length lower limb and whole
spine radiography. Dietrich TJ, Pfirrmann CW, Schwab A, Pankalla K, Buck FM. Skeletal Radiol.
2013.
Notes de l'éditeur
Of course the most important for us is the diagnostic confidence so I am going to speak about EOS images and more especially about stitching , image quality, magnification and measurements.
..
…..
To give you an idea of our progression we started in october 2014 and basically we have 2 time more patients since the beginning with now aournd 8 patients / day , sometimes 20.
